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The DSM-5 and the Biological Underpinnings of Problem Gambling: What Science Can Tell Us—and What It Means

by Responsible Gambling Council | Mar 01, 2013 12:36 PM

Newscan (Vol. 15, Issue 8)

Dr. Marc Potenza, a professor of psychiatry, child study and neurobiology at the Yale University School of Medicine and the director of the Problem Gambling Clinic, presented at the closing plenary session of Discovery 2013.

Dr. Potenza has made a significant impact on problem gambling research over the last 15 years. He has been part of two DSM-5 research work groups and the majority of this work has focused on understanding the clinical and neurobiological underpinnings of gambling and related disorders, and their co-occurrences with other mental health disorders. “There is almost no one I can think of better positioned to give us a deeper understanding of the fundamental nature and complexity of problem gambling,” says Dr. Jamie Wiebe of RGC’s Centre for the Advancement of Best Practices, "with a view to new and emerging treatment options."

In a recent conversation with Dr. Potenza, he gave us a glimpse into some of the insights he shared at Discovery 2013.

You plan to provide a historical perspective. Why is that important now?

While I would say that a historical perspective is always important, this year especially so because of the upcoming changes to the DSM-5 that signal some important changes to society’s view of gambling. In that context, it’s important to look back at other points in history where gambling, and problem gambling, were reconceptualised. Every change significantly refocuses the lens on problem gambling.

Gambling, as a human activity, is as old as civilization (for example, a prince loses his fortune, and his wife, in a dice game in the Sanskrit epic Mahabharata, dating back to the 4th century BCE). And, just as old as gambling itself, is the pendulum swing of its social acceptance — one need only look in the U.S., where lotteries were initially used to support government and educational initiatives in the colonial period, then banned in the late 19th century, and then re-introduced by states in the latter part of the 20th century.

Throughout all of these changes, what have we learned?

Superimposed on these changes in public attitudes is the development of our understanding of the biological underpinnings of gambling and gambling disorders. When diagnostic criteria for pathological gambling first entered the DSM-III in 1980, it was classified as a “disorder of impulse control not elsewhere classified.”

A proposed move in the DSM-5 involves classifying together gambling and substance-use disorders together as addictive disorders. This development is largely because of major breakthroughs in our understanding of the commonalities in the factors (including neurobiological) that underlie addictions, whether substance-related or not.

When I started in the field in the mid 1990s, little was known about the epidemiology of problem gambling; there were no published neuroimaging studies, and little in the way of randomized clinical trials. Since then, neuroimaging, genetic and pharmacotherapy studies, as well as examinations of concurrent disorders, have taught us an enormous amount about problem and pathological gambling.

Where do we need to go from here?

Despite these advances, there is still no medication that is approved in the US or Canada with an indication for the treatment of pathological gambling, despite decades of successful integration of drug therapy into mental health treatment. By contrast, significant developments in treatments for other disorders, such as depression, involved a shift in the understanding of disorders from being afflictions people could “just get over” to illnesses relating to physiological brain factors. This has led directly to advances in treatment, both behavioural and drug-related, that have had profound impacts on modern society.

While it’s impossible to predict, a change like this—where gambling disorders are grouped with substance-use disorders—could lead to some very exciting developments, both in terms of research and in terms of the practical application of that research in prevention, treatment and public policy. For example, while there is plenty of evidence that problem gambling treatment of various types does help people, there is a lot to be learned about how it works, and for whom. By integrating research in brain imaging, genetics and clinical trials, there is an enormous opportunity to understand the mechanisms of effective behavioural change, and then tailor programs to increase their reach and success rates.

Interested in hearing from more leading experts? Join RGC at Discovery 2017 in Toronto, April 18-20.
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